Instructions: 2.3 contact hours will be awarded for this activity. A contact hour is 60 minutes of instruction. This is a Learner-paced Program. Vindico Medical Education does not require submission of the quiz answers. A contact hour certificate will be awarded 4–6 weeks following receipt of your completed Registration Form, including the Evaluation portion. To obtain contact hours:
Read the article: “Continuing Education Needs of Nurses in a Voluntary Continuing Nursing Education State,” on pages 107–115, carefully noting the tables and other illustrative materials that are provided to enhance your knowledge and understanding of the content.
Read each question and record your answers. After completing all questions, compare your answers to those provided within this issue.
Type or print your full name and address and your Social Security number in the spaces provided on the Registration Form. Indicate the total time spent on the activity (reading article and completing quiz). Forms and quizzes cannot be processed if this section is incomplete. All participants are required by the accreditation agency to attest to the time spent completing the activity.
Forward the completed Registration Form with your check or money order for $15 made payable to JCEN-CNE. Payment must be in U.S. dollars drawn on a U.S. bank. CNE Registration Forms are accepted up to 24 months from date of issue.
Vindico Medical Education is an approved provider of continuing nursing education by the New Jersey State Nurses Association, an accredited approver by the American Nurses Credentialing Center’s Commission on Accreditation. P188-6/09-12.
This activity is co-provided by Vindico Medical Education and The Journal of Continuing Education in Nursing.
Objectives: After studying the article, “Continuing Education Needs of Nurses in a Voluntary Continuing Nursing Education State,” in this issue, the participant will:
Discuss the importance of continuing nursing education and its application to practice.
Describe the benefits of and barriers to participation in voluntary continuing nursing education.
Explain priority learning needs identified by registered nurses participating in this study.
Discuss implications for nursing education, practice, and research.
Dr. Nalle is Assistant Professor and Coordinator, Continuing Nursing Education; Dr. Wyatt is Assistant Professor; and Dr. Myers is Assistant Professor, University of Tennessee College of Nursing, Knoxville, Tennessee.
The authors disclose that they have no significant financial interests in any product or class of products discussed directly or indirectly in this activity, including research support.
The authors thank the Tennessee Nurses Association, the Tennessee Hospital Association, the Tennessee Organization of Nurse Executives, and the Nursing Continuing Education Consortium for their participation and support of this study.
Address correspondence to Maureen A. Nalle, PhD, RN, University of Tennessee, College of Nursing, 1200 Volunteer Boulevard, Knoxville, TN 37996-4180.
A long-held standard of professional nursing practice, the goal of continuing education is to enhance practitioner competence and improve public health through lifelong learning (American Nurses Association, 2004). According to Price, Akpanudo, Dake, and Telljohann (2004), continuing education helps to eliminate gaps between formal preparation and practice, enhances clinical skills, and promotes the development of knowledge and skills necessary for continued professional competence. In a rapidly changing health care environment, current and relevant continuing education is integral to maintaining a safe health care environment and a highly competent work force (Levett-Jones, 2005; Penz, D’Arcy, Stewart, Kosteniuk, Morgan, & Smith, 2007).
Despite ongoing debate on the relationship between continuing education and competency (Griscti & Jocono, 2006; Jordan, Thomas, Evans, & Green, 2008; Smith, 2004), nursing has maintained its commitment to continuing nursing education (CNE) as a mechanism for ensuring practice excellence and quality of care. Although state board requirements for registered nurses (RNs) and licensed practical nurses vary, continuing education is currently the most common method of demonstrating professional competence (Scott-Tilley, 2008). Currently, 28 states (56%) require CNE for license renewal and certification, or demonstration of professional competence, with a trend toward more states implementing such mandates (Yoder-Wise, 2008).
Continuing education mandates have been shown to influence nurses’ participation (Smith, 2004), although there is little research related to nurses’ motivation, educational needs, and participation in voluntary continuing education. There is a particular need for this type of research to guide and sustain the continuing education efforts of both professional organizations and other CNE providers. The goals of the current study were to identify learning needs to guide continuing education planning at the organizational, regional, and state levels of nursing practice, and to explore the relationship between state RN demographics (employment status, educational background, and certification) and continuing education practices.
Review of the Literature
Motivation for Continuing Nursing Education Participation
Early research on the effect of voluntary versus mandatory continuing education on nurses’ beliefs about the value of CNE and their motives for participation showed that increased knowledge, career advancement, and professional competence were more important motivators than compliance with certification or licensure requirements (Thurston, 1992; Waddell, 1993). Supporting the evidence of competence as a primary motivator, DeSilets (1995) also noted differences in motivation to obtain CNE according to educational level. Cooper (1997) and Ryan (2003) subsequently showed that nurses’ CNE participation was intrinsically motivated by enhanced knowledge and professional skills rather than by extrinsic factors or regulatory requirements. RNs in Harper’s (2000) study participated in voluntary CNE to remain current and believed that CNE enhanced their competence. Improved patient care and enhanced professional relationships have also been identified as incentives for nurses’ involvement in continuing education activities (Smith & Topping, 2001).
Although voluntary participation may foster motivation for continued learning, nurses appear to value continuing education, regardless of voluntary or mandatory status (Prater & Neatherlin, 2001), and accrue a similar number of contact hours, with or without a mandate (Kubsch, Henniges, Lorenzoni, Eckardt, & Oleniczak, 2003; Smith, 2004). These findings support the need to understand both the organizational and regulatory context for continuing education and its influence on nurses’ motivations, educational needs, and voluntary participation in CNE activities.
According to Robertson, Umble, and Cervero (2003), comprehensive assessment of learner needs is a key variable in program effectiveness and improved professional knowledge, skills, and performance. As the first step in educational planning, a needs assessment ensures relevance of continuing education programs for the potential audience (Pololi, Dennis, Winn, & Mitchell, 2003) and provides the foundation for development of program objectives, content, and targeted learning activities (DeSilets, 2007). Although there are clear professional guidelines for needs assessment as a foundation for CNE (Claflin, 2005), evidence of systematic needs analyses in the current nursing literature is somewhat limited (Griscti & Jacono, 2006).
Alexander, Chadwick, Slay, Petersen, and Pass (2002) conducted a national survey of maternal-child health nurses to determine learner preferences, capacity for training, and current educational efforts. Claflin (2005) explored differences in nurses’ learning needs according to age, education, and work-related characteristics (shift worked), identifying the contextual nature of continuing education needs. In a national sample of adolescent health nurses, Saewyc, Bearinger, McMahon, and Evans (2006) identified perceived competencies, educational needs, and preference for continuing education methods. Penz et al. (2007) examined CNE participation and perceived barriers among a targeted population of rural nurses.
Assessment of educational needs may be conducted at multiple levels: a micro-level assessment focused on a specific organization or professional group or a macro-level assessment focused on the continuing education needs of multiple organizations (Gould, Kelly, White, & Chidgey, 2004). Griscti and Jacono (2006) also recommend that needs assessment be done in collaboration with other stakeholders to ensure relevance to specific professional groups and nursing work environments. The current study used a collaborative, micro-level approach to identify the learning needs of nurses from diverse settings to support CNE planning at the local, regional, and state levels of nursing practice.
The objectives of this statewide needs assessment were to: (1) describe the demographics and professional characteristics of RN responders, (2) identify priority learning needs of state RNs, and (3) describe relationships between RN demographics and professional characteristics, continuing education needs, and participation in continuing education. Institutional review board approval was obtained from the sponsoring university. All RNs in the state were eligible to participate in the online needs assessment.
Professional nursing groups in the state were informed about the research study and its purpose and methods through professional meetings, websites, and newsletters. Participating organizations (the state nurses’ association, the board of nursing, the hospital association, the organization of nurse executives, and the center for nursing) consented to participate through e-mail notification of members. An announcement was posted on the organization’s website 1 week before the needs assessment was posted. A regional continuing education consortium, representing six large health care organizations, also disseminated the needs assessment to their nurse employees through internal communication channels.
Instrumentation and Analysis
The instrument was constructed based on a review of relevant professional literature, educational and clinical experience of the authors, and technological considerations for an online instrument. The needs assessment consisted of 25 items, primarily multiple-choice questions and several items requiring a write-in response. Ten questions related to demographics and professional characteristics, including nursing experience, education, professional memberships, and employment information. Fifteen questions focused on continuing education access, participation, priorities, and learning needs, such as the primary reason for CNE participation and factors most likely to influence participation. Some items permitted multiple responses, such as identification of learning needs and barriers to pursuing continuing education.
A first draft of the needs assessment was reviewed by a panel of 15 stakeholders from a regional continuing education consortium. This panel provided recommendations and revisions to improve the content validity and clarity of the instrument. A paper version was then pilot tested with a small number of RNs (n = 8), resulting in slight revisions to wording and answer options. Before publication, several RNs also completed the online version of the instrument to resolve usability and technical issues.
Internet technology and the online format were used for rapid data collection, broad needs assessment of a target population, and streamlined data analysis (Morris, Fenton, & Mercer, 2004). The survey was developed with SelectSurvey software. After receiving website or e-mail notification, respondents were linked to a web page for specific study information. An online consent form described procedures, storage of survey responses, and use of data for continuing education planning. Participants gave consent by selecting an “I accept” button that automatically loaded the needs assessment pages. Each item on the needs assessment required a response before the participant could advance to the next page. Some items allowed write-ins to accommodate individual responses.
The online needs assessment was accessible to RNs for 4 months. On average, participants completed the survey in approximately 20 minutes. Responses were stored on a secure server accessible only to the researchers; all data were exported into SPSS version 16.0 for analysis. After elimination of incomplete needs assessments, a total of 672 responses were included in the data analysis. Demographic data were analyzed using descriptive statistics, including frequencies, means, and cross-tabulations. Questions with multiple responses were analyzed using multiple response tables to evaluate relationships between demographics, professional characteristics, continuing education needs, and participation in continuing education. Results for multiple-response questions are reported as a percentage of respondents (percentage totals may exceed 100%) who selected the option, not a percentage of total responses (percentages equal 100%).
Because public access websites were the main recruitment strategy, the exact number of participants recruited cannot be determined. However, more than 800 of the state’s 72,000 RNs (Tennessee Center for Nursing, 2007) responded to the needs assessment. Table 1 shows the final sample of 672 registered nurses, representing fewer than 1% of licensed RNs in the state, with a geographic distribution of 55% from the eastern region, 26% from the middle region, and 19% from the western region of the state. Nurses with professional certification (55%) were better represented than those without certification, and many RNs (46%) reported having graduate degrees. Respondents also represented a diversity of 45 professional roles and nursing positions. Staff nurses were the most widely represented (27%), followed by nurse practitioners (17%) and academic faculty (13%). Nineteen percent of the RNs held at least two positions, and 6% reported at least three professional roles. A majority of RNs (69%) reported more than 16 years of professional experience, whereas 8% had 5 or fewer years in nursing.
Table 1: Sample Demographics (N = 672)
Nearly all respondents reported membership in a professional nursing organization (86%), with a majority (57%) as members of the American Nurses Association and the state constituent member association. Sixty percent of the nurses were also members of a specialized practice organization (Table 1).
Continuing Nursing Education Perceptions and Practices
Needs assessment items related to continuing education were designed to assess both current practices of individual nurses and perceived needs and availability of CNE opportunities. Nurses were asked to describe their reasons for pursuing continuing education, rate its importance to their practice, and report the number of nursing continuing education hours they had obtained in the last 2 years. Across all groups, 43% of respondents identified personal and professional interest as their primary reason for participation, with master’s- and bachelor’s-prepared nurses more likely to respond in this category. Licensure requirements (15%) and career advancement (12%) were also identified as main reasons for CNE participation. Only 5% reported job requirements as a rationale for participation in continuing education. One quarter of the responses to this item fell into the category of other reasons (Table 2).
Table 2: Continuing Nursing Education Perceptions and Practices (N = 672)
Nurses rated continuing education in their current role as either very important (59%) or important (29%). Consistent with these findings, 72% had participated in 15 or more hours of continuing education in the last 2 years, with greater levels of participation noted as educational level increased. Nearly 90% of those with a master’s degree in nursing or a doctorate had accrued more than 15 hours of continuing education in the last 2 years.
Reporting on their last 2 years of continuing education activities, 29% of nurses identified clinical knowledge and skills and 24% selected specialty clinical content as priority topics. Leadership and management was a priority topic for 15% of respondents, and 11% identified employer/Joint Commission-mandated topics as priorities. Nurses who held an associate’s degree were more likely to identify participation in employer/Joint Commission-mandated topics than in other continuing education opportunities. More than 20% of survey responses fell into the category of other topics (Table 2).
Sources of continuing education identified by this sample of nurses are also shown in Table 2. Current employer offerings were the most frequent source of contact hours for 37% of nurses. A national professional conference was the second most frequent source (32%). Journal and print offerings were identified by 12% of respondents, and 11% reported online continuing education as their major CNE source. Only 8% of respondents chose other in response to this item. Master’s-prepared nurses and those who held doctorates were more likely to use journal and print offerings to obtain contact hours than were diploma-, associate’s-, or bachelor’s-prepared nurses.
In relation to nurses’ personal participation in continuing education activities, 33% reported the opportunity to influence practice as a primary influence. The influence of professional certification and license renewal requirements was reported by 23% and 20% of nurses, respectively. Only 11% of nurses were influenced by salary, and few nurses were influenced by paid days off or career ladder opportunities (Table 2). Among all respondents, nurse practitioners and clinical educators cited the opportunity to influence practice as their greatest influence; nurse practitioners and staff nurses were more influenced by certification requirements and academic faculty were primarily influenced by license renewal requirements.
Benefits of and Barriers to Continuing Nursing Education Participation
Nurses were also asked to identify the benefits of pursuing continuing education, rate its importance to professional practice, and list the factors most likely to influence their participation (Table 3). Eighty-three percent of nurses reported improved knowledge and skills as the primary benefit of continuing education. Both professional growth and personal growth were recognized as positive outcomes (79% and 59%, respectively), and 64% of nurses reported critical thinking and decision-making as a major benefit. Interestingly, only 52% of nurses identified better patient outcomes as a significant benefit of CNE participation, yet 33% believed that CNE influenced their practice.
Table 3: Benefits of and Barriers to Continuing Nursing Education Participation
Although the majority of respondents valued CNE and its influence on practice, they also experienced numerous barriers to pursuing continuing education opportunities (Table 3). Program cost was a major barrier for 74% of respondents. Time away from work (56%), lack of funding (54%), and travel requirements (49%) were also reported as significant barriers to CNE participation. Twenty-five percent of nurses identified a lack of relevant programs as a barrier, although program relevance received the lowest rating by all groups.
Priority Learning Needs
Assessment of priority learning needs was one of the most important aspects of the current study. From a comprehensive list of clinical and professional topics, nurses were asked to select three priority topics for continuing education. Across multiple respondent categories and diverse areas of professional practice, the priority areas for continuing education were identified as leadership and management (28%), evidence-based practice (26%), professional issues (21%), advanced practice (21%), and acute medical-surgical nursing (18%) (Table 4). Fewer than 15% of nurses prioritized any other aspect of professional learning or clinical practice for continuing education.
Table 4: Priority Learning Needs
Despite a small representation of the state’s licensed RN population, the large study sample included a diverse cross-section of nursing practice from each geographic region of the state. Staff nurses, advanced practice RNs, and academic faculty were particularly responsive. There are several possible explanations for the greater participation among these groups. First, the recruitment method through state professional associations and professional websites may favor bachelor’s-, master’s-, and doctorate-prepared nurses, who constitute a large membership in the American Nurses Association and specialty nursing organizations. Certified or advanced practice nurses are frequently required to obtain a predetermined number of continuing education contact hours for license renewal, providing an additional impetus for survey participation.
The major findings of this needs assessment support previous research relative to nurses’ motivations for participation in CNE and its value to their practice. As Griscti and Jacono (2006) reported, factors influencing CNE participation were related to individual, professional, and organizational perspectives. Specifically, individual factors, such as educational level, influenced nurses’ perceptions about and participation in continuing education activities. Professional factors, such as certification, and the nonmandatory nature of continuing education provided additional context for nurses’ decisions about continuing education and its effect on their practice.
Response rates among nurses with advanced degrees suggest that education is a predictor of continuing education participation (Beatty, 2001; Kubsch et al., 2003). Kubsch et al. (2003) noted that associate’s- and diploma-prepared nurses were more likely to be motivated by job-related factors, whereas nurses with higher education levels pursue continuing education for personal and professional reasons. Advanced practice nurses may also accrue a greater number of contact hours to meet certification or license renewal requirements. Nurses prepared at the master’s and doctoral levels perceive more influence on their practice and patient care, and thus may be more motivated to obtain CNE (Ulrich, Buerhaus, Donelan, Norman, & Dittus, 2005).
Membership in a professional nursing organization was not a prerequisite for study participation, although the majority of nurses did report at least one membership. As the sample reflects, membership may be associated with advanced education, certification, or specialty practice. Smith (2004) reported a link between membership in a professional organization and increased interest and participation in professional development and continuing education activities; access to CNE opportunities may provide an incentive for membership, just as membership provides an opportunity and incentive for CNE participation.
Similar to Smith’s (2004) study, the workplace was identified as an important source of continuing education, including clinically focused content and Joint Commission-mandated topics. Although many nurses expressed satisfaction with employer offerings, the work environment did not address all learning needs, as evidenced by participation in multiple other CNE methods. Reported barriers to CNE participation, such as program cost, time away from work, and travel requirements, are consistent with the findings of earlier studies (Alexander et al., 2002; Penz et al., 2007), suggesting both economic and resource limitations that affect nurses’ ability to attend and pay for CNE programs.
The priority continuing education needs identified in the current study may reflect the demands of the current work environment as well as participants’ diverse practice roles. Claflin (2005) acknowledged the contextual nature of nurses’ learning needs, reporting a high preference for clinical topics and less interest in professional issues among staff nurses. Other research suggested a preference for continuing education that directly relates to competence in the areas of practice (DeLeskey & Fetzer, 2007). A greater emphasis on professional topics, such as leadership and management and evidence-based practice, may be related to a relatively high representation of nurse educators and advanced practice nurses in the sample population. Gallagher (2007) also suggested that nurses want to see the relationship among continuing education, practice, and client care, making the interest in evidence-based practice particularly relevant. The fact that few nurses identified priority learning needs in non-clinical areas, such as health promotion, research, and health information systems, is not surprising, given the majority of staff nurses in the sample. However, a more targeted approach may show different learning needs among nurses in specialty areas of practice.
Several limitations have been identified in the current study. From the perspective of sample size, the small number of participants cannot be viewed as representative of the state RN population. Also, this RN population does not represent a random sample. With distribution to “primary sites” (professional organizations), followed by dissemination to other groups, there is no way to accurately assess how many people received the needs assessment but did not reply. The significantly higher number of responses from the eastern region of the state suggests greater awareness and professional distribution opportunities within the region of the academic sponsor site.
An online needs assessment method may affect response rates as a result of Internet access or technical abilities of potential participants. Among health professionals, the high volume of e-mail and lack of incentives may contribute to poor response rates for online and web-based needs assessments (Kittleson & Brown, 2005). The use of professional organizational channels for e-mail distribution may also limit access by the general nursing population, resulting in an incomplete perspective of RN learning needs.
As in previous research, nurses have self-identified their continuing education needs and priorities. Self-report methods have limited value in explaining nurses’ continuing education values, beliefs, and motivations (Smith & Topping, 2001), and they may not reflect actual learning needs in terms of competencies for role performance (Bernstein, Reiber, Stolz, Shapiro, & Connors, 2004). Therefore, priority learning needs, perceived value and influence of continuing education, and CNE participation among this sample of nurses should be interpreted within this context.
Through the collaborative efforts of CNE planners and diverse professional groups, an educational needs assessment was conducted to provide direction for local, regional, and statewide continuing education efforts. An accurate assessment of learning needs and motivating factors, such as educational preparation, certification status, and the context for nursing work, is a primary consideration for achieving the goals of CNE.
An important finding is that nurses functioning in a variety of roles need and value timely, affordable, quality continuing education. The current study confirmed the complexity of factors that influence nurses’ CNE participation and demonstrated their motivation to advance and improve their practice, even in the absence of regulatory mandates. The study also identified leadership and management and evidence-based practice as priority learning needs for nurses across practice settings. Nurses recognized many benefits related to CNE participation, most importantly, enhanced knowledge and skills and increased competence for practice. Significant and persistent barriers related to program cost, time away from work, and lack of funding for attendance were also reported. Beyond the important foundation of needs assessment, these findings may provide a better understanding of motivations for and barriers to nurses’ CNE participation and provide some direction for CNE program planners at the local, regional, and state levels.
Application to Practice
Although it is an unproven influence on client outcomes, CNE is certain to retain its importance as a vehicle to promote and maintain nurses’ competence for practice. The growing demand for continued competence in nursing practice will require greater personal commitment and improved professional policies and resources (Jordan et al., 2008). More effective strategies are needed to address barriers, such as access, funding, and quality of continuing education programs (Penz et al., 2007).
Health care organizations, professional associations, and individual professionals will be challenged to create and sustain these efforts through practice, education, and research.
Of primary importance is the need to demonstrate the effect of continuing education on nursing competence and patient outcomes, as well as to validate the cost-benefit of funding for continuing professional education (Griscti & Jacono, 2006). Exploration of the effect of CNE on nurse retention and job satisfaction may also promote greater organizational support and funding. Future research may support and expand the findings of the current study relative to individual, professional, and organizational influences on nurses’ continuing education activities in both voluntary and mandatory CNE environments.
Collaboration among clinical staff educators, nursing faculty, and other stakeholders would provide opportunities for a more in-depth assessment of learning needs and better direction for continuing education programs (DeSilets, 2007). Nurse educators and CNE provider organizations have a key role in the development and implementation of high-quality programs tailored to nurses’ learning priorities. Increased use of technology and web-based and distance learning opportunities should be explored to address persistent barriers related to cost, time, and access.
Because health care organizations are primary sources of continuing education for their staff, more needs to be done to support nurses’ professional development efforts and remove organizational barriers to participation. Based on nurses’ satisfaction with employer offerings, program quality and relevance must be enhanced, with a focus on clinical learning priorities that have direct application to practice. Professional associations can also make a significant contribution through ongoing programs for nurses in specialty practice and advanced practice roles.
Fletcher (2008) confirmed that continuing education will become increasingly important as nurses are challenged to improve the quality of patient care, ensure professional competence, and provide accountability to the public. Through leadership in health care organizations and professional associations, nurses must be active partners in the process of advocating for effective organizational policies and ensuring quality CNE opportunities. The additional challenge is to establish nursing education and research partnerships that promote evidence-based CNE and meet community continuing education needs.
- Alexander, G., Chadwick, C., Slay, M., Petersen, D. & Pass, M. A. (2002). Maternal and child health graduate and continuing education needs: A national assessment. Maternal and Child Health Journal, 6(3), 141–149. doi:10.1023/A:1019715227618 [CrossRef]
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Sample Demographics (N = 672)
| Staff nurse
| Nurse practitioner
| Academic faculty
| Clinical educator
| Associate’s degree in nursing
| Bachelor’s degree in nursing
| Bachelor’s degree
| Master’s degree in nursing
| Master’s degree
| None identified
| American Nurses Association/state constituent member association
| Specialty organization
Continuing Nursing Education Perceptions and Practices (N = 672)
|Reason for participation
| Personal and professional interest
| Licensure requirement
| Career advancement
| Job requirement
|Most recent continuing nursing education topic
| Clinical knowledge and skills
| Specialty clinical content
| Leadership and management
| Employer/Joint Commission-mandated
|Source of continuing nursing education
| Employer offering
| National conference
| Journal or print offering
| Online continuing education
|Personal influence on continuing nursing education participation
| Opportunity to influence practice
| Professional certification
| Licensure requirement
| Salary increase
| Paid days off
| Career ladder opportunities
Benefits of and Barriers to Continuing Nursing Education Participation
| Improved knowledge and skills
| Professional growth
| Critical thinking and decision-making
| Personal growth
| Better patient outcomes
| Program costs
| Time away from work
| Lack of funding
| Travel requirements
| Program relevance
Priority Learning Needs
|Leadership and management
|Acute medical-surgical nursing